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Minnesota Lawful Gambling <br />LG230 Application to Conduct Annual Off -Site Gambling <br />Pagel of 2 <br />3/01 <br />No Fee <br />Licensed Organization Information (please print all information) <br />Organization Name OA! P /iJer 4/6(/VI"CGwe, License Number (5 digits) 0// L <br />License Expiration Date 4616. / '3 / / 2 0G)1 Class of Organization License 0 B, C, or D) <br />Daytime Phone <br />Number (76, 3 ) 7,430 ffo2 <br />Name of Chief Executive Officer LAfi2V Mib1.'4of ? <br />(Do not list the gambling manager) <br />Gambling Premises Information (_ _ <br />Name of establishment/function where gambling activity will be conducted J '/ .�JL-) //_f e'ffU11f% Di=g /CG L -/ --' <br />Street Address and City /7/ 67 -/1/ .072/ a—rj Ljit/ 47LCI /1 4/. fl J/y <br />(Do not use a post office box. If no street address, write in the road designations. Example: 3 miles east of Hwy. 63 on County Road 42) <br />Lease Requirement. Does your organization own the gambling premises? <br />Fl If yes, no lease is required. <br />If no, a lease agreement must be attached (you may use lease form LG224, available from the Board). However, no lease is required if the <br />only gambling activity to be conducted is a raffle. <br />Date(s) for off -site activity up to 12 consecutive <br />days: <br />Begin date 0 17i / /3 / 0 .2.- <br />End date 0 % // 3 /02 <br />Type of Gambling Activity. Check the box(es) for the <br />gambling activity your organization will be conducting. <br />0 Pull -Tabs El Bingo EJ Tipboards <br />Raffles n Paddlewheels <br />Local Unit of Government Acknowledgment <br />If the gambling premises is within city limits, the city must sign this application and provide a resolution. <br />On behalf of the city, I acknowledge that this application <br />will be forwarded to the appropriate city officials, the city Print name of city <br />must pass a resolution specifically approving or denying <br />this application, and a copy of the resolution will be <br />forwarded to the applying organization. (Signature of city personnel receiving application) <br />Title Date / <br />/ <br />If the gambling premises is located in a township, both the county & township must sign this application. <br />The county must provide a resolution. <br />For the township: On behalf of the township, I <br />acknowledge that the organization is applying for an Print name of township <br />annual off -site gambling activity within the township <br />limits. <br />/ <br />A township has no statutory authority to approve or (Signature of township official acknowledging application) <br />deny an application (Minn. Stat. 349.213, subd. 2). Title Date / <br />For the county: On behalf of the county, I acknowledge <br />that this application will be forwarded to the appropriate Print name of county <br />county officials, the county must pass a resolution <br />/ <br />specifically approving or denying this application, and a (Signature of county personnel receiving application) <br />copy of the resolution will be forwarded to the applying <br />organization. Title Date / <br />Chief Executive Officer (CEO) Acknowledgment and Oath <br />I have read this application, and all information is true, accurate, and complete. I hereby authorize the Gambling Control <br />Board to modify the class of organization license to be consistent with the class of permit being applied for. <br />(.1:___ <br />> % <br />� <br />CEO Signature � <br />/ .•- -(�°-� l`T r: -��i,).rte i Date / / j/ / <br />